How to Get Medi-Cal to Pay for a Gastric Bypass

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Gastric bypass surgery is a lifesaving procedure that allows many overweight people to live a healthy, prosperous life. Gastric bypass surgery is a procedure in which the stomach is made smaller and a large portion of the intestines are bypassed by connecting a portion of the intestines directly to the stomach. Though Medi-Cal does not exclude gastric bypass surgery from their coverage, the costs of the surgery (ranging from $20,000 to $50,000) require that a solid case about why Medi-Cal should cover the surgery must be made.

How to Get Medi-Cal to Pay for a Gastric Bypass

Ask your primary care doctor for a referral to a bariatric surgeon. Ask the surgeon to obtain a pre-authorization for the surgery from Medi-Cal. In some cases, approval is granted and Medi-Cal will pay for the surgery without further ado.

Ask your doctor to write a letter of medical necessity if Medi-Cal does not grant the pre-authorization for your surgery. Ensure that your doctor includes your current weight, the length of time that you have been overweight and all medical conditions that you suffer from due to your obesity in the letter. Patients are required to be morbidly obese, which is defined as having a BMI (Body Mass Index) of greater than 40 in order to qualify for gastric bypass surgery. The BMI of a patient is determined by a ratio of a patient's height to the patient's weight. Patients and doctors are able to determine BMI by using a calculator (see the Resources section for a link).

Gather information pertaining to all weight loss programs that you have tried to lose weight with and failed with in the past. Include all official documents from commercial weight loss programs and medically supervised programs. This is necessary information in order to show Medi-Cal that you have tried to lose weight in the past to no avail and do, in fact, need to undergo a gastric bypass procedure.

Mail your doctor's letter of necessity and your information regarding your previous weight loss attempts to Medi-Cal. Ensure that the packet is mailed with a tracking number and delivery confirmation to verify that Medi-Cal receives the information.

Reply immediately to all correspondence initiated by Medi-Cal. Appeal all denials. Include all new, pertinent, information regarding your condition with your correspondence. For example, if you have developed another medical condition or a current medical condition has gotten worse due to your obesity, be certain to include that information from your physician.

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References

  • Medi-Cal
  • "Introduction to U. S. Health Policy : Organization, Financing, and Delivery of Health Care in America;" Donald A. Barr; 2007
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